Pre-hospital trauma care on the battlefield differs greatly than pre-hospital trauma care practiced in the private sector. The types and severity of injuries are different than those encountered in civilian settings and combat medical personnel face multiple additional challenges in caring for their wounded teammates in a tactical setting. They must provide care while under hostile fire, often working in the dark with multiple casualties and limited equipment. They must also often contend with prolonged evacuation times as well as the need for tactical maneuvering superimposed upon their efforts to render care.

Enter TCCC….

In the mid-1990s, a Special Operations medical research project was undertaken with the goal of improving the survivability of combat trauma injuries by improving the kind of care rendered on the battlefield. This research effort developed a new concept called Tactical Combat Casualty Care (TCCC) and proposed a set of pre-hospital trauma care guidelines that were customized for use on the battlefield. This effort was focused on the most common historical causes of preventable death in combat. The TCCC guidelines were quickly adopted by the Navy Sea, Air, and Land (SEAL) community, the 75th Ranger Regiment, and later by a few other military units. With increasing reports of success from units using the techniques advocated by TCCC, this new approach to battlefield trauma care began to spread throughout the US military. The tri-service Committee on TCCC (CoTCCC) was begun in 2001 to ensure that emerging technology and information is incorporated into the TCCC guidelines on an ongoing basis. The membership of the CoTCCC includes combat medics, Corpsmen, and PJs as well as physicians and physician assistants. The Committee is a standing multi-service committee charged with monitoring medical developments in regards to practice, technology, pharmacology and doctrine. New concepts in hemorrhage control, airway management, fluid resuscitation, analgesia, antibiotics and other lifesaving techniques are important steps in providing the best possible care for our Marines and Sailors in combat.

What is the primary intent of TCCC?

The primary intent of TCCC is to reduce preventable combat death through a means that allows a unit to complete its mission while providing the best possible care for casualties.

What are the principles of TCCC?

Tactical Combat Casualty Care (TCCC) is intended to treat potentially preventable causes of death on the battlefield, but acknowledges that application of these treatments may place the provider and even the mission in jeopardy if performed at the wrong time. Therefore, TCCC classifies the tactical situation with respect to health care provision into 3 phases (care under fire, tactical field care and tactical evacuation) and only permits certain interventions to be performed in specific phases based on the danger to the provider and casualty.

What are the phases of Care?

In TCCC prehospital battlefield care is divided into 3 phases:

Care Under Fire (CUF)- CUF is characterized as the care rendered to a casualty while still under effective fire. In this case, the first action is to return fire and take cover as fire superiority over the enemy is the best medicine to include the casualty remaining engaged if able. As an enemy is suppressed, casualties can move or be move to more secure positions. The only medical treatment rendered in CUF if stop life-threatening hemorrhage (bleeding). TCCC actively endorses and recommends the early and immediate use of tourniquets to control massive external hemorrhage of limbs. All other treatment should be delayed until the casualty can be moved to a more secure and covered position and transitioned to tactical field care.

Tactical Field Care (TFC) - TFC is care rendered by first responders or prehospital medical personnel (primarily medics) while still in the tactical environment. TFC is focused on assessment and management using the MARCH or DRSABCDE acronym. Massive hemorrhage is managed through the use of tourniquets, hemostatic dressings, junctional devices, and pressure dressings. The airway is managed by rapid and aggressive opening of the airway to include cricothyroidotomy for difficult airways. Respirations and breathing is managed by the assessment for tension pneumothorax and aggressive use of needle decompression devices to relieve tension and improve breathing. Circulation impairment is assessed and managed through the initiation of intravenous access followed up by administration of tranexamic acid (TXA) if indicated, and a fluid resuscitation challenge using the principles of hypotensive resuscitation. TCCC promotes the early and far forward use of blood and blood products if available over the use colloids and discourages the administration of crystalloids such as normal saline (sodium chloride). Hypothermia prevention is an early and critical intervention to keep a traumatized casualty warm regardless of the operational environment. Continued assessment and management in TFC includes treating penetrating eye trauma, assessing for traumatic brain injury or head injuries, treating burns, spling fractures, and dressing non-life-threatening wounds. TCCC promotes the early and aggressive use of analgesia (pain management) on the battlefield through the administration of Ketamine and/or Oral Tranmuccossal Fentanyl for casualties with moderate to severe pain. TCCC also promotes the early administration oral and intravenous or intramuscular antibiotics. The remainder of TFC care is dedicated is reassessment of injuries and interventions, documentation of care, communicating with tactical leadership and evacuation assets. TFC culminates with packaging a casualty for evacuation and then evacuating by available air, ground, or maritime assets.

Tactical Evacuation Care (TACEVAC) - TACEVAC care encompasses the same assessment and management included in TFC with additional focus on advanced procedures that can be initiated when en route to a medical treatment facility. The caveat of TACEVAC is the evacuation means and care may or may not be dedicated medical platforms such as a MEDEVAC helicopter. TACEVAC can also include the evacuation of casualties on available non-medical assets and the provision of care in such circumstances.

How can I find out more?
To find out more, visit the website of the Committee of Tactical Combat Casualty Care - www.cotccc.com